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COPYRIGHT 2004 A Thomson Healthcare Company
The first part of this series discussed abdominal pain in pediatric patients. This second and final part will cover abdominal pain in elderly, immunocompromised, and pregnant patients.
--The Editor
The Older Patient
Those 65 years of age and older constitute the fastest-growing segment of the population, and currently comprise about 12% of the U.S. population. (1) This means that abdominal pain in the elderly will be a commonplace occurrence in EDs. (See Table 1 for common causes of abdominal pain.) In the elderly, the history may be more difficult to obtain due to the higher frequency of problems with communication, such as hearing impairment, dementia, and stroke. (1) The symptoms in this age group are less specific and often atypical--they tend to present with less pain, less systemic symptoms such as fever, and have fewer laboratory abnormalities such as leukocytosis. (1,2) They also tend not to develop signs of peritonitis, namely involuntary guarding and rebound. (2)
The distribution of diagnoses here differs from other segments of the population, and the disease often is more complicated due to co-morbid conditions. (1,2) Furthermore, there often is a delay in presentation due to lack of transportation or fear of institutionalization. (2) This leads to complicated disease upon presentation.
Van Geloven and colleagues studied 180 elderly patients presenting to the ED with abdominal pain. They constituted 5% of those with abdominal pain in the ED. However, these patients had an 86% admission rate; 27% of these required surgery, and the mortality rate was 17%. (3) Although this is a European study, where the utilization of ancillary diagnostic tests such as computed tomography (CT) scan was low (11%), it highlights some of the challenges of diagnosing and managing abdominal pain in the elderly. A recent U.S. study documented a rate of surgery of 22.1% in those 65 years of age and older. The authors found that the presence of hypotension, abnormal abdominal radiographs, leukocytosis, abnormal bowel sounds, and advanced age correlated with an adverse outcome in those 65 and older. (4)
Bowel Obstruction. Bowel obstruction is a common cause of abdominal pain in the elderly and is the second most common cause for a surgical intervention in this age group. (5)
Large and Small Bowel Obstruction. Neoplasms are the most common cause of large bowel obstruction (LBO), followed by diverticulitis and volvulus. LBO symptoms typically develop over days. The patients present with abdominal distention, colicky abdominal pain, and obstipation. Vomiting may be absent. The diagnosis of LBO usually is confirmed by an acute abdominal series showing a distended colon with the typical haustral pattern (not crossing the full width of the bowel) and air-fluid levels with more than 20 mm of height difference when measured in the same bowel loop in cases of a mechanical obstruction. (6)
Adhesions are the most common cause of small bowel obstruction (SBO), followed by hernias and neoplasms. (2,7) The patients complain of colicky intermittent abdominal pain. Six clinical variables have a high sensitivity and positive predictive value for the diagnosis of SBO: previous abdominal surgery, history of constipation, age older than 50 years, vomiting, abdominal distention, and increased bowel sounds ("tinkles and rushes"). (8)
The diagnosis can be confirmed with an acute abdominal series showing distended bowel loops that are centrally located and show bands that traverse the entire bowel width (valvulae conniventes). (See Figure 1.) The CT scan will not only confirm the obstruction, but often will show the level of the obstruction and its possible cause. (9)
[FIGURE 1 OMITTED]
Volvulus. Gastric volvulus is more frequent in the elderly, followed by colonic volvulus. In the geriatric population, sigmoid volvulus is the most common type of colonic volvulus, accounting for 65-80% of cases. It has a 20-40% mortality rate. (10) Cecal volvulus is the second most common type of volvulus, accounting for 15-20% of cases. Volvulus of the transverse colon and splenic flexure are rare and comprise only 2-5% of cases. The peak age for presentation is in the 50s, and typically the patients are either debilitated or institutionalized. (11,12) Chronic constipation secondary to inactivity and use of neuropsychiatric drugs that alter bowel motility increase the likelihood of volvulus in these patients. The typical presentation is that of chronic constipation, followed by crampy low abdominal pain, progressive abdominal distention, and then vomiting and obstipation. On physical examination, there is marked distention and tympany to percussion. This distention can result in respiratory compromise. Peritonitis can be evident, and usually is due to bowel strangulation.
The diagnosis of sigmoid volvulus usually is confirmed by plain films of the abdomen, which show a single dilated loop of colon on the left half of the abdomen. (See Figure 2.) The barium enema will show the pathognomonic "bird's beak" appearance. (13)
[FIGURE 2 OMITTED]
The management is mainly supportive, with early surgical consultation. If not strangulated, the sigmoid volvulus often can be reduced using a sigmoidoscope or a barium enema. (5) Operative reduction is needed for those with a cecal volvulus, strangulation, or the rare perforation. (14)
Remember that neoplasms are the most common cause of LBO, and adhesions are the most common cause of SBO.
Biliary Tract Disease. Biliary disease is the most common indication for abdominal surgery in the elderly. (15-18) The incidence of cholelithiasis is 20-50% in those older than 70 years, and it is more common in women. (18,19) Cholelithiasis also is more common in certain ethnic groups, such as those of Mexican heritage and Native Americans. Besides the increased prevalence of gallstone disease in this group, the elderly also have more complications from acute cholecystitis, such as gangrene or perforation.
Ascending cholangitis is rare before 70 years of age and carries a high mortality. (20) It is a bacterial infection within an obstructed or poorly draining biliary system. The condition often is defined by the presence of Charcot's triad: right upper quadrant abdominal pain, fever, and jaundice. Acute suppurative cholangitis has Reynold's pentad, which adds mental confusion and hypotension to Charcot's triad. (5) It carries a 100% mortality if the biliary tree is not decompressed urgently. Another condition more commonly seen in the elderly is acalculous cholecystitis. Risk factors for acalculous cholecystitis are diabetes, parenteral nutrition, and the use of opiates. The mortality rate is 15%. (21) Mirizzi's syndrome is jaundice in acute cholecystitis due to ductal compression from an edematous gallbladder. (21) Gallstone ileus is another cause of intestinal obstruction in the elderly. The condition has a 15% mortality rate. (22) Gallstones cause about 50% of the cases of acute pancreatitis, what is termed gallstone pancreatitis. The condition has a higher mortality than alcoholic pancreatitis. Finally. bile peritonitis also is a complication of acute cholecystitis. (2) The gallbladder ruptures, spilling bile in the peritoneum, which causes a diffuse inflammatory reaction.
Patients with biliary tract disease and acute cholecystitis will present with right upper quadrant pain, usually post-prandial, and vomiting. However, the clinical findings in the elderly do not correlate with the severity of the disease. (18) Up to 25% of patients have no previous biliary symptoms. The majority of patients with cholecystitis are afebrile at presentation, and approximately 30-40% will fail to develop leukocytosis.
Ultrasound (US) is the preferred test to confirm the diagnosis of cholelithiasis and acute cholecystitis. In the hands of an experienced operator, its accuracy for detecting gallstones is 95-98%, but for ductal stones is only 20-55%. (21) US is safe, non-invasive, accurate, rapid to perform, and easy to perform. US reliably shows gallbladder stones and sludge, with the characteristic acoustic shadowing. It also shows signs of acute cholecystitis, such as gallbladder wall thickening (greater than 3 mm), pericholecystic fluid, biliary tree dilatation, and gas in the biliary tree and gallbladder wall. (23) The Murphy's sign also can be reproduced using the US probe. (24) The HIDA scan is better than the US at identifying acute cholecystitis and acalculous cholecystitis, but not as widely available. (5,18) For those with biliary duct disease, endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard. ERCP has the benefit of being both diagnostic and therapeutic. Magnetic resonance cholangiopancreatography (MRCP) also is used infrequently due to its tow availability and high cost.
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